Usage
Calcium citrate malate (CCM) is primarily prescribed to prevent and treat hypocalcemia, a condition characterized by low blood calcium levels. It’s also used to manage conditions arising from calcium deficiency, such as osteoporosis, osteomalacia/rickets, and hypoparathyroidism. Additionally, it can be beneficial in latent tetany (a muscle disease) and ensuring adequate calcium intake in specific groups like pregnant/nursing women, postmenopausal women, and individuals on certain medications (e.g., phenytoin, phenobarbital, prednisone). CCM is classified as a calcium supplement and belongs to the category of minerals and electrolytes.
CCM works by providing a readily absorbable form of calcium, which is essential for various bodily functions including nerve transmission, muscle contraction, bone formation, and blood clotting.
Alternate Names
There are no widely recognized alternate names for calcium citrate malate itself. However, the term “calcium citrate” is often used interchangeably, although CCM is a more bioavailable form specifically combining citric acid and malic acid with calcium. Some brand names include Citracal.
How It Works
Pharmacodynamics: Calcium is a crucial element for bone mineralization, nerve impulse transmission, muscle contraction, and various enzymatic reactions. CCM elevates serum calcium levels, thereby addressing the effects of hypocalcemia.
Pharmacokinetics: CCM is absorbed in the small intestine, facilitated by the presence of citric and malic acid, which enhance solubility and absorption, especially in individuals with achlorhydria or malabsorption. It is metabolized and utilized as needed by the body, with excess calcium excreted primarily through the kidneys. Vitamin D enhances calcium absorption. Specific information on metabolism by CYP enzymes isn’t readily available. Elimination mainly occurs through renal excretion, with a smaller portion eliminated in feces.
Dosage
Standard Dosage
Adults: 1000 mg of elemental calcium per day for adults aged 19-50, increasing to 1200 mg/day for women over 50 and men over 70. This should be divided into doses of 500 mg or less taken with meals for optimal absorption (calcium citrate may be taken without food).
Children: Dosage varies with age:
- 200 mg/day (under 6 months)
- 260 mg/day (6-12 months)
- 700 mg/day (1-3 years)
- 1000 mg/day (4-8 years)
- 1300 mg/day (9-18 years)
Pediatric safety should be assessed regarding potential choking hazards with tablets and appropriate formulations used.
Special Cases:
- Elderly Patients: Dosage remains as per standard adult recommendations, but close monitoring of renal function and serum calcium levels is advisable.
- Patients with Renal Impairment: Dose reduction may be necessary in severe renal impairment; consult guidelines for dose adjustment based on creatinine clearance.
- Patients with Hepatic Dysfunction: No specific dose adjustment is generally needed for hepatic dysfunction.
- Patients with Comorbid Conditions: Consider interactions and adjust as needed; special care with conditions involving calcium metabolism, such as sarcoidosis.
Clinical Use Cases
Dosage for these scenarios is individualized based on patient-specific needs and serum calcium levels, typically falling within the standard dosage range for adults/children unless contraindicated. Continuous monitoring of electrolytes is essential, particularly in critical care settings.
Dosage Adjustments
Adjustments are based on serum calcium levels, renal function (creatinine clearance), co-administered medications, and any presence of underlying medical conditions. Genetic polymorphisms affecting drug metabolism are not currently a major consideration for CCM dosing.
Side Effects
Common Side Effects:
Constipation, nausea, upset stomach, flatulence, belching.
Rare but Serious Side Effects:
Hypercalcemia (symptoms: nausea, vomiting, loss of appetite, confusion, lethargy), milk-alkali syndrome (with chronic high dosing), kidney stones.
Long-Term Effects:
Kidney stones with prolonged excessive intake.
Adverse Drug Reactions (ADR):
Severe hypercalcemia, milk-alkali syndrome.
Contraindications
- Hypercalcemia
- Severe renal impairment
- Milk-alkali syndrome
- Hypersensitivity to calcium citrate or any component of the formulation
- Ventricular fibrillation
- Renal calculi
- Hypophosphatemia
Drug Interactions
CCM can decrease the absorption of certain medications like bisphosphonates, tetracycline antibiotics, quinolone antibiotics, levothyroxine, estramustine, and digoxin. It can interact with phosphate binders and thiazide diuretics. Other interactions may occur with cellulose sodium phosphate and certain phosphate binders (calcium acetate). Alcohol, caffeine, and soft drinks can inhibit calcium absorption. Separate administration times for interacting drugs is recommended. Consult a drug interaction database for a comprehensive list.
Pregnancy and Breastfeeding
CCM is generally considered safe during pregnancy and breastfeeding; however, it’s crucial to ensure the dosage is within recommended limits. Excessive vitamin D intake during pregnancy should be avoided. Calcium appears in breast milk.
Drug Profile Summary
- Mechanism of Action: Provides supplemental calcium, essential for bone health, nerve function, muscle contraction.
- Side Effects: Common: constipation, nausea. Serious: hypercalcemia, milk-alkali syndrome, kidney stones.
- Contraindications: Hypercalcemia, severe renal impairment, milk-alkali syndrome, hypersensitivity.
- Drug Interactions: Bisphosphonates, tetracyclines, quinolones, levothyroxine, digoxin, phosphate binders.
- Pregnancy & Breastfeeding: Generally safe within recommended dosages.
- Dosage: Varies with age and condition; consult dosage section.
- Monitoring Parameters: Serum calcium levels, renal function tests (in chronic use or renal impairment).
Popular Combinations
CCM is often combined with Vitamin D to enhance calcium absorption.
Precautions
Standard precautions apply regarding pre-screening for allergies and assessing renal function, particularly in elderly patients and those with pre-existing kidney conditions. Caution advised with sarcoidosis, heart disease, and pancreatic disease.
FAQs (Frequently Asked Questions)
Q1: What is the recommended dosage for Calcium Citrate Malate?
A: Please see the detailed Dosage section above as recommendations vary widely based on age, medical conditions, and other factors.
Q2: What are the primary uses of CCM?
A: Preventing and treating hypocalcemia, managing osteoporosis and related conditions, supporting adequate calcium intake in certain populations.
Q3: How is CCM different from calcium carbonate?
A: CCM is generally better absorbed, especially in those with low stomach acid.
Q4: Can CCM be taken with other medications?
A: Yes, but potential drug interactions exist; consult the Drug Interactions section and a pharmacist or drug interaction checker for details.
Q5: Are there any long-term risks associated with CCM use?
A: Excessive intake can lead to kidney stones.
Q6: Can CCM be used during pregnancy?
A: Generally considered safe within the recommended dosage.
Q7: What are the common side effects?
A: Constipation, nausea, and gastrointestinal upset.
Q8: Who should avoid taking CCM?
A: Individuals with hypercalcemia, severe renal impairment, or milk-alkali syndrome.
Q9: How should CCM be stored?
A: Store in a cool, dry place away from direct sunlight.
Q10: Is CCM safe for children?
A: Yes, with appropriate dosing adjustments based on age; choose child-friendly formulations when available.
